Benefits Consultants
Tim B. Piatchek, LUTCF, LC

Serving the Ozarks and

Southwest Missouri

since 1968!

Call us locally at 417-877-1567 or Toll-Free at 866-716-4555
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MEET TIM!

Individual Health Plan

Group Health Plan

Term Life Insurance

IRA - Annuities - 401K Rollover - Retirement Planning

Group Health Plans

The quote you are requesting requires that you complete the following survey as completely and accurately as possible. Once submitted, your information is e-mailed to our office and we will process your request. This information is kept confidential and used for quote purposes only.

*Required fields marked in yellow

Contact Information
*Company Name:
*Type of Business:
*Name:
*Address:
*City:	State: Zip:
*Phone:	Work:
	Home:
	Fax:
Email Address:

Type of Coverage
Doctor Visit Copay:	Yes No
Hospital Deductible:
Coinsurance:
Health System Preference:
Optional Coverage:	Maternity Prescription Card Supplemental Accident
List any specific companies you would like quotes from:
List any major medical conditions associated with any individuals/dependents listed below: (cancer, diabetes, heart)
List any prescription medications associated with any individuals/dependents listed below:

Census Information
Please list all individuals, spouses, and dependents you wish to cover.
Name	Date of Birth	Age	Gender	Employment
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
# of dependents			Male Female	Full Time Part Time
If you have more than 25 employees, just submit this form additional times. On the additional submissions, only enter your company name and the additional employee information as needed.

Additional Considerations/Requests

Please add any comments/questions not covered above.

Please click on the "Send Request" button to send us your quote request.

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Contact Information

Type of Coverage

Census Information

Additional Considerations/Requests